Authorization Form - York Area Earned Income Tax Bureau
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1Employee Name : _____________________________ SS# ________________
Street Address :__________________________________
City _____________ State ____ Zip Code ________
I, ______________________________ am a resident of the following municipality and school district.
Municipality ______________________ School District ____________________________
The rate presently is 1%. As of 7/2/02 – (3) school districts - Dover, Southern and West Shore have tax rate increases. See
Notification of tax rate changes which were mailed to all employers and residents of those school districts.
If an employee fails or refuses to give the above information, 1 % is the correct amount of local earned income tax to be withheld and
remitted to the York Area Earned Income Tax Bureau, any additional tax due then becomes the employee’s responsibility.
I hereby authorize my employer to withhold my local earned income tax at a percentage rate of __________ and remit the
withholding to York Area Earned Income Tax Bureau. P. O. Box 15627 York, PA 17405.
Signature: _________________________________
Date: _____________
Employee Name : _____________________________ SS# ________________
Street Address :__________________________________
City _____________ State ____ Zip Code ________
I, ______________________________ am a resident of the following municipality and school district.
Municipality ______________________ School District ____________________________
The rate presently is 1%. As of 7/2/02 – (3) school districts - Dover, Southern and West Shore have tax rate increases. See
Notification of tax rate changes which were mailed to all employers and residents of those school districts.
If an employee fails or refuses to give the above information, 1 % is the correct amount of local earned income tax to be withheld and
remitted to the York Area Earned Income Tax Bureau, any additional tax due then becomes the employee’s responsibility.
I hereby authorize my employer to withhold my local earned income tax at a percentage rate of __________ and remit the
withholding to York Area Earned Income Tax Bureau. P. O. Box 15627 York, PA 17405.
Signature: _________________________________
Date: _____________
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